{"paper_id":"27bbee2c-cd50-437c-b4ed-cff6de6d76bd","body_text":"The economic burden of ventriculoperitoneal shunt insertion and its complications: Findings from a cohort in the Philippines | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The economic burden of ventriculoperitoneal shunt insertion and its complications: Findings from a cohort in the Philippines Kevin Ivan P. Chan, Abdelsimar Tan Omar II, Kathleen Joy O. Khu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4578687/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Ventriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost. Methods We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015–2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost. Results A total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8 months (range: 7 days – 8 years). Over a median follow-up of 222 days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5,425) than uncomplicated patients (PHP 40,587.20 or USD 779; p < 0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1,671; p < 0.001). Conclusion The study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost. Economic burden ventriculoperitoneal shunt shunt malfunction shunt infection developing country INTRODUCTION The burden of congenital hydrocephalus remains high, especially in low- and middle-income countries (LMICs). [ 1 ] Ventriculoperitoneal shunt (VPS) insertion, the standard of treatment for hydrocephalus, is one of the most commonly performed neurosurgical procedures, with approximately 5.5 per 100,000 patients undergoing VPS implantation annually. [ 2 ] However, VPS insertion is fraught with complications, and has a high likelihood of revisions and/or replacement requiring repeated admissions and operations.[ 3 – 5 ] Despite improvements in surgical technique and consistent use of perioperative antibiotics, shunt malfunction and infection occur in up to 41% and 7% of cases, respectively.[ 6 , 7 ] Shunt failure and infection result in significant neurologic morbidity for the patient. Survivors of shunt infections have decreased intelligence quotients, increased frequency of seizures, increased psychomotor retardation, and decreased quality of life overall.[ 6 , 8 , 9 ] Aside from the adverse effects on clinical outcomes, shunt failure also carries a significant financial burden on the family unit and on health systems. Its total expenditure per year has been estimated at 2 billion dollars in the United States.[ 8 ] Despite this, only a few studies on the inpatient cost of shunt infection and malfunction have been published. [ 4 , 5 , 11 – 13 ] Moreover, most of these studies were in high-income countries, even when the burden of hydrocephalus is much greater in LMICs. [ 4 , 5 , 11 – 13 ] We thus conducted a retrospective cohort study in a public hospital in the Philippines to determine the cost of initial VPS insertion for congenital hydrocephalus, as well as the cost of subsequent admissions and operations for the management of shunt infection and shunt malfunction. We compared our findings with similar costing studies performed in other countries. We also determined which demographic and clinical characteristics were predictive of cost. These results can provide insight on the financial burden of VPS insertion in LMIC settings, and inform healthcare utilization decisions and cost-effectiveness studies. MATERIALS AND METHODS Study Design We performed a retrospective cohort study involving review of medical charts and financial records at the Philippine General Hospital, the largest public tertiary hospital in the country. We analyzed data of service patients, whose hospitalization is funded by government-provided health insurance, with no or minimal out-of-pocket expenditure. We followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement guidelines for observational studies.[ 14 ] Patient Selection We included all pediatric patients (aged 18 years and below) with a diagnosis of congenital hydrocephalus admitted during a 5-year period from January 2015 until December 2019, and who underwent one or more of the following surgical procedures: (1) initial VPS insertion; (2) shunt revision or insertion of a new VPS for shunt malfunction; and (3) shunt removal with or without temporary ventricular drainage for shunt infection. Shunt malfunction is defined as a non-infectious entity comprising of shunt blockage, shunt breakage, or dislodgement with the need for subsequent shunt surgery.[ 15 , 16 ] Meanwhile, shunt infection is diagnosed by the identification of a microorganism on gram stain or culture from cerebrospinal fluid (CSF) or wound swab, CSF pleocytosis obtained from a shunt tap associated with fever and/or shunt malfunction, clinical signs of wound infection, and/or peritonitis in a patient with a VPS. [ 17 ] Because COVID infection was a confounding variable which would intuitively increase cost, data from the year 2020 onwards were intentionally not included in the study. We excluded the following patients: congenital hydrocephalus associated with spina bifida or meningoceles; hydrocephalus secondary to tuberculous meningitis, brain tumors, hemorrhage, or trauma; and patients who left against medical advice or transferred to other institutions prior to completing treatment. Data collection The inpatient hospitalization cost was determined from the hospital billing records. Medical implants used for CSF diversion such as VPS kits, Ommaya reservoirs, and external ventricular drainage (EVD) systems were not available in the hospital pharmacy and had to be sourced outside, so their costs were estimated based on the current retail price and added to the total cost. The following patient data were collected: age, sex, etiology of congenital hydrocephalus, length of hospital stay for each admission, presence of co-morbidities complicating the course of hospitalization, and outcomes of treatment. Statistical analysis Baseline characteristics were summarized using means and standard deviations for the continuous measures and frequencies and percentages for categorical variables. Differences among groups were tested using one-way ANOVA for continuous variables (using the Bonferroni method to correct for multiple comparisons, when appropriate) and Chi-squared tests for categorical variables. To account for inflation across the 5-year study period, we converted the raw in-hospitalization cost for the years 2015–2018 to its 2019 equivalent with a consumer price index calculator for the Philippine peso (PHP) ( https://www.worlddata.info/asia/philippines/inflation-rates.php ). To analyze predictors of total cost of hospitalization, we conducted univariate linear regression model to assess the association of the following variables with cost: exposure category (uncomplicated, shunt malfunction, or shunt infection), age, sex, etiology, presence of comorbidities at baseline, presence or absence of other infections complicating the hospital course, number of surgeries, and length of stay. We also performed multivariable linear regression model, including the same predictors. The assumptions of linear regression – normality, linearity, and homoscedasticity – were checked by examining residual plots. The level of statistical significance was set at p < 0.05. To compare the in-hospitalization costs in our study with data reported in other countries, we performed a detailed literature review. We converted all mean cost values to their equivalent US dollar (USD) value on January 1 of the last year of the data collection period using a currency converter with historical data ( https://www.xe.com/currencytables ). We then converted the USD value to its January 2019 equivalent with the consumer price index calculator described above to account for inflation. RESULTS A total of 230 CSF diversion procedures for congenital hydrocephalus were performed from 2015–2019. These were performed on 125 patients across 151 admissions, and included initial VPS insertions and subsequent re-do operations. The mean age of the cohort during the index VPS insertion was 9.8 months (range: 7 days to 8 years), with a slight female predilection (1.2:1). The most common etiology of the hydrocephalus was aqueductal stenosis (44%). Comorbidities were present in 32.8% of patients, and these included central diabetes insipidus, transient tachypnea of the newborn, and other congenital anomalies. Twenty-five patients (20%) had concomitant infection, most commonly hospital-acquired pneumonia. Out of the 230 CSF diversion procedures performed, 107 were initial VPS insertions while 123 were re-do operations that addressed a shunt complication. Of the 125 patients included, 85 (68%) had an uncomplicated course, 15 (12%) were complicated by shunt malfunction, and 25 (20%) were complicated by shunt infection over a median follow up of 222 days. Patients with a shunt-related morbidity consulted at the emergency department with signs of malfunction or infection at a mean of 3.2 years (range: 14 days to 8 years) from the initial VPS insertion. For the patients who developed shunt infection, 54% had a positive microbial growth on CSF culture. Patients who had shunt malfunction underwent an average of 2 operations (range: 1–4). The operation most commonly performed was a shunt revision. On the other hand, patients who had shunt infection underwent a median of 3 operations (range: 3–17). The types of procedures used to address the shunt infection were shunt removal and EVD insertion (64%), shunt removal only (24%), and shunt exteriorization (12%). Some patients had repeated bouts of ventriculitis and underwent EVD replacement while waiting for the infection to resolve. Once the infection was treated, majority (92%) underwent repeat VPS insertion. All the patients were discharged home after treatment. (Table 1 ) Table 1 Baseline characteristics and total cost of admission of patients who underwent shunt surgery with an uncomplicated course, complicated by shunt malfunction, and complicated by shunt infection Overall Uncomplicated Course Shunt Malfunction Shunt Infection p-value Number 125 85 15 25 Age at initial shunt, in months (SD) 9.8 (16.4) 8.6 (11.7) 24.2 (35.3) 5.5 (5.2) < 0.001 Sex Male Female 67 (53.6%) 58 (46.4%) 47 (55.3%) 38 (44.7%) 9 (60%) 6 (40%) 14 (56%) 11 (44%) 0.530 Etiology of congenital HCP Aqueductal stenosis Dandy-Walker syndrome Hydranencephaly Others 55 (44%) 21 (16.8%) 8 (6.4%) 41 (32.8%) 41 (48.2%) 14 (16.5%) 7 (8.2%) 23 (27.1%) 3 (20%) 4 (26.7%) 0 8 (53.3%) 11 (44%) 3 (12%) 1 (4%) 10 (40%) Co-morbidities present 41 21 2 18 < 0.001 Concomitant infection Pneumonia Sepsis Urinary tract infection 25 12 2 11 4 1 1 0 0 13 8 1 < 0.001 < 0.001 0.400 Mean number of operations (SD) 1.8 (2.0) 1.0 (0) 1.7 (0.9) 4.8 (3.1) < 0.001 Type and number of procedures VPS insertion Shunt revision Shunt removal, ± EVD insertion Shunt removal, Ommaya EVD insertion/ revision ETV Shunt Exteriorization Ventriculoatrial shunt insertion 230 119 85 85 N/A N/A N/A N/A N/A N/A N/A 26 5 18 1 0 1 1 0 0 119 29 11 13 2 47 6 10 1 Mean length of stay per admission (days) 31 13 12 102 Mean length of stay for total treatment (days) 34.1 (54.9) 12.2 (14.2) 16.7 (13.2) 118.9 (73.3) < 0.001 Mean cost of total treatment (PHP) 94,573.50 40,587.20 87,065.70 282,631.60 < 0.001 Mean cost of total treatment (USD) 1,815 779 1,671 5,424 *EVD - external ventricular drain; ETV – endoscopic third ventriculostomy; HCP – hydrocephalus; PHP – Philippine peso; SD – standard deviation; USD – United States dollar The mean length of stay for all patients was 34 days, with a significant difference among groups (uncomplicated, shunt malfunction, shunt infection; p < 0.001). The mean length of stay for uncomplicated patients (12.2 days) and those with shunt malfunction (16.7 days) were both significantly lower than the mean for patients with shunt infection (118.9 days, p < 0.001). The mean cost of hospitalization for all patients was P94,573.50 (range: PHP 16,735.90–915,609.40), and was also significantly different among groups. In particular, pairwise analyses with the Bonferroni correction showed that the mean cost of patients who had shunt infection (PHP 282,631.60) was statistically higher than the mean cost for uncomplicated patients (PHP 40,587.20, p < 0.001) and the mean cost for patients who had malfunction (PHP 87,065.70, p < 0.001). Univariate analysis showed the following significant predictors of total cost: occurrence of shunt infection, presence of comorbid congenital malformations at baseline, pneumonia and sepsis complicating the course of hospitalization, number of surgeries, and total length of stay. Multivariable analysis to determine the association of the predictors with the total hospitalization cost yielded a model that did not meet the assumptions of normality on analysis of residual plots. We thus proceeded to regress the log of the raw cost on the predictors. This yielded a model which met the assumptions for linear regression. This model was able to explain 79% of the observed variability (adjusted R-squared: 0.7914). The following remained as significant predictors of cost in the latter model: shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). (Table 2 ) Table 2 Univariable and multivariable analysis of predictors of total cost of treatment p-value Univariate Multivariate* Exposure category Uncomplicated Ref. Ref. Malfunction 0.053 < 0.001 Shunt Infection < 0.001 < 0.001 Age 0.839 0.509 Sex 0.837 0.283 Etiology Aqueductal stenosis Ref. Ref. Dandy-Walker malformation 0.424 0.382 Hydranencephaly 0.892 0.085 Post-meningitic hydrocephalus 0.400 0.251 Arachnoid cyst 0.661 0.829 Schizencephaly 0.130 0.133 Malformations of cortical development 0.720 0.271 Presence of comorbidities at baseline 0.001 0.516 Infection Pneumonia < 0.001 0.006 Sepsis 0.001 0.004 UTI 0.560 0.442 Number of surgeries < 0.001 0.066 Length of stay < 0.001 0.005 *Multivariate regression DISCUSSION This study is the first to report the inpatient hospitalization cost of VPS insertion for congenital hydrocephalus and its complications in the Philippines, and is only the second study performed in a low- and middle-income country (LMIC). The mean cost of VPS insertion for congenital hydrocephalus in the Philippines was P94,573.50 (USD 1,815.23) for all patients and PHP 40,587.20 (USD 779) for those who did not develop any shunt complications. The cost was comparable to the one reported in Uganda, another LMIC, which showed a mean cost of USD 620 for an uncomplicated VPS insertion.[ 18 ] These values were only a fraction of the cost of the procedure in high-income countries. For example, studies from Australia, Canada, and the United States reported a mean cost of USD 11,836–62,850 for an uncomplicated shunt procedure after adjusting for inflation [ 4 , 5 , 10 – 13 ] (Table 3 ). These were 15 to 80 times more expensive than the mean cost in our cohort. The large disparity in cost may have been due to the setting of the study. Our institution is a public government hospital where physicians do not charge patients any fee for service. Moreover, the patients stayed in large hospital wards instead of individual rooms. Differences in the standard of care between developed and developing countries may also play a role. Table 3 Comparison of the cost of treatment for VPS insertion and its complications in other countries Author, year Period covered Country (WB classification) Uncomplicated shunt Shunt Malfunction (per admission) Shunt Infection (per admission) Mean cost (raw) Mean cost in USD (Jan 2019) Length of stay (days) Mean cost per admission (raw) Mean cost in USD (Jan 2019) Length of stay (days) Mean cost per admission (raw) Mean cost in USD (Jan 2019) Length of stay (days) Chan 2024 2015–2019 Philippines (LMI) PHP 40,587 779 13 PHP 52,303 1,004 12 PHP 225,564 4,329 102 Pham 2013[ 5 ] 2007–2009 Australia (HI) AUD 13,905 11,836 7.3 AUD 9,753 8,139 4.9 AUD 83,649 69,904 50 Shannon 2011[ 11 ] 2000–2005 USA (HI) NR NR NR USD 3,964 5,232 2 USD 23,541 31,541 12 Warf 2011[ 18 ] 2005 Uganda (LMI) USD 470 620 NR USD 875 1,155 NR NR NR NR Stone 2010[ 21 ] 2005–2006 USA (HI) USD 15,103 19,555 NR NR NR NR 90,257 116,864 NR Simon 2008[ 12 ] 2003 USA (HI) USD 40,260 55,773 6.8 USD 17,760 24,589 2.6 USD 62,470 86,540 15 Patwardhan 2005[ 10 ] 2000 USA (HI) USD 35,816 53,408 8.4 NR NR NR NR NR NR Bigio 1998 [ 13 ] 1990–1996 Canada (HI) CAD 52,812 62,850 NR NR NR NR NR NR NR *AUD – Australian dollar; CAD – Canadian dollar; LMI – low- and middle-income; HI – high-income; NR – not reported; USA - United States of America; USD – US dollar; WB – World Bank Unsurprisingly, treatment costs increase if shunt complications occur. Although both shunt malfunction and infection will require re-operation, the management of these two disease entities differs greatly, translating into a large difference in treatment cost.[ 11 ] Shunt malfunction without infection is usually managed with a single surgical intervention, such as revising the obstructed ventricular or peritoneal catheter or shunt valve. On the other hand, shunt infection requires at least two surgical interventions, namely, removal of the existing shunt system with or without EVD insertion, and insertion of a new shunt after completing a lengthy course of antibiotic treatment, making this type of shunt failure significantly more costly. [ 11 , 19 ] An interesting finding was that in the 5-year study period, the number of re-do operations due to shunt complications outnumbered that of initial VPS insertions (123 re-do to 107 initial shunts). These numbers suggest that more resources are devoted to the treatment of shunt complications than to the initial shunt procedures. This is in contrast with a study done in the USA which showed that more initial shunt insertions were performed than re-do operations. [ 10 ] In addition, the patients in our shunt infection subgroup underwent a mean number of 5 operations whereas patients in a US center with the same diagnosis underwent only 2.28 revisions. [ 20 ] It has been established that the high cost of VPS treatment predominantly arose from the relatively high complication and revision rates.[ 4 ] In our study, the mean cost of treatment of shunt malfunction without infection was PHP 87,066 or USD 1,671. This value is 2.1 times the cost of treatment of an uncomplicated VPS insertion (USD 779). For shunt infection, however, the mean cost of treatment was PHP 282,631.60 or USD 5,424.79, which is 7 times the cost of an initial shunt insertion. In comparison, patients with shunt malfunction in Uganda spent USD 1,155, which was nearly twice the cost of VPS insertion (USD 620). [ 18 ] In the USA and Australia, shunt malfunction cost USD 3,964 − 24,589 per admission, with a mean length of hospital stay ranging from 2 to 4.9 days. [ 5 , 11 , 12 ] In terms of shunt infection, the costs ranged from USD 31,541 to 116,864 in the USA and Australia [ 10 , 11 ], which were several magnitudes larger than in our cohort (USD 5,639). However, the average length of stay was only 12–15 days in the USA [ 10 , 11 ] and 50 days in Australia[ 5 ]. These were in stark contrast to the mean hospital stay of 119 days in our cohort. Aside from shunt infection and malfunction, other predictors of cost included pneumonia, sepsis, and length of hospital stay. Studies in other settings showed similar findings and determined the following predictors for cost: shunt infection [ 5 , 8 , 21 ], pre-operative comorbidities[ 10 , 12 , 13 ], number of surgeries [ 10 ] and the length of stay [ 11 , 22 ]. Notably, all the significant predictors we have identified in our study were modifiable risk factors and could serve as targets of improvement initiatives. In fact, given our data, by averting one case of shunt infection, the hospital can reallocate resources and surgically treat 7 other patients with congenital hydrocephalus. Possible contributory factors Risk factors for shunt complications include patient-related and treatment-related factors. [ 26 , 27 ] The patients in our cohort were from the lower income classes who could not afford expensive private medical care. It has been reported that patients’ ethnicity and socioeconomic status were significantly associated with VPS morbidity and mortality rates.[ 8 ] A lower socioeconomic status was a significant predictor of higher cost of hospitalization for VPS insertion. [ 23 ] Furthermore, hydrocephalus treatment in the developing world may be complicated by nutritional deficiencies, low infant birth weight, lower APGAR score, greater incidence of perinatal and neonatal infections, and delayed antenatal diagnosis. [ 28 , 29 ] Several of our patients had concomitant systemic infections that may have contributed to the risk of shunt infection. In our study setting, the majority of the VPS operations were performed by neurosurgery trainees. Studies have shown that the shunt complication rates were significantly higher in trainees than in attending neurosurgeons.[ 30 ] In addition, antibiotic treatment and antimicrobial resistance may present challenges in a developing country. The questionable quality of pharmaceutical products[ 31 ], suboptimal antibiotic dose[ 32 ], lack of appropriate drug regulatory mechanisms[ 33 ], lack of more potent antibiotics[ 34 ], and inappropriate prescription practices [ 33 ] may lead to inadequate treatment of infection. [ 32 , 33 ] Burden at many levels Although the cost of shunt insertion in the Philippines is lower compared to developed countries, it is important to emphasize that out-of-pocket payment is the largest source of healthcare funding in the country, comprising nearly half (47.9%) of the funding. [ 35 , 36 ] Given that a Filipino family has an average monthly income of PHP 26,083 (USD 500) and average annual savings of PHP 75,000[ 37 ], a single hospital admission for an uncomplicated VPS insertion (USD 779) already poses a significant economic burden. The cost will increase even more for patients who develop shunt complications. Moreover, there are indirect costs of treatment such as lost income for the child’s parents. Warf et al. elucidated the possible opportunity cost lost by the parents while their children were admitted for shunt failure. [ 18 ] The patients’ parents were mostly minimum salary workers, so the opportunity cost of their time, which could be spent earning, poses a burden on the family. [ 5 , 18 ] Our findings should serve as a wake-up call for the proper and timely management of congenital hydrocephalus and avoidance of treatment complications, directed towards healthcare providers, hospital administrators, and policy makers in the health sector. Although effective protocols for the prevention of shunt failure are beyond the scope of this paper, an optimistic recommendation would be to decrease the shunt malfunction and infection rates with the hope of lowering the cost of treatment. This study places a monetary value on shunt insertion, malfunction, and infection, and highlights the exorbitant costs associated with shunt failure. In this regard, budget reallocation to prevent shunt infection and malfunction may prove to be more cost-effective in the long run. Furthermore, clinical and cost-analysis research protocols should be aimed at decreasing the infection rate and cumulative shunt revision rates, which would ultimately result in improved patient outcomes and substantial cost savings. Lastly, the burden of hydrocephalus and its treatment and failure is intertwined with more general public health concerns such as malnutrition, communicable diseases, congenital risk factors, and parental education. Limitations This paper has several limitations. First, this is a retrospective study with its inherent biases. Second, we only included patients with congenital hydrocephalus, and excluded patients with other forms of congenital lesions such as myelomeningocoele and those with acquired hydrocephalus. The cost of the treatment in these cases is expected to be higher compared to the costs presented in this paper. Third, the data was gathered from a public government hospital that serves indigent patients, so the costs of treatment are lower and would not be reflective of the costs in other hospitals in the country, especially the private ones. In addition, the members of the healthcare team did not charge patients for their services, contributing to a lower cost. Fourth, only the inpatient medical records were included in the review. Patients who underwent an initial VPS insertion and developed shunt failure may have consulted at other hospitals after the initial surgery, so the cost of their treatment would not be reflected in this study. Lastly, the reported costs were only limited to direct quantifiable cost during the patient’s hospitalization, as reflected in the billing records. Indirect costs such as the potential loss of income of the parents and cost of outpatient visits, imaging studies, and medication were not included. CONCLUSION This study described the cost of VPS insertion and its complications. Predictors of cost included shunt infection, malfunction, pneumonia, sepsis, and length of stay. These can be potential targets of improvement initiatives to favorably affect health outcomes and reduce costs. Abbreviations APGAR Apperance Pulse Grimace Activity Respiration score AUD Australian Dollars CAD Canadian dollar CSF Cerebrospinal fluid EVD External ventricular drain LMIC Low- and middle-income country PHP Philippine peso USA United States of America USD US dollar VPS Ventriculoperitoneal shunt Declarations Author contributions KPC: conceptualization, methodology, data curation, formal analysis and investigation, writing – original draft preparation, writing – review and editing; ATO: conceptualization, methodology, formal analysis and investigation, writing – original draft preparation, writing – review and editing; KOK: conceptualization, methodology, formal analysis and investigation, writing – original draft preparation, writing – review and editing, supervision Funding The authors did not receive any support from any organization for the submitted work. Competing interests The authors have no relevant financial or non-financial interests to declare. 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Pol J Radiol 79:444–449. 10.12659/pjr.890540 Curry CJ, Lammer EJ, Nelson V, Shaw GM, Schizencephaly (2005) Heterogeneous etiologies in a population of 4 million California births. Am J Med Genet A 137A(2):181–189. 10.1002/ajmg.a.30862 Tuli S, Drake J, Lawless J, Wigg M, Lamberti-Pasculli M (2000) Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 92(1):31–38. 10.3171/jns.2000.92.1.0031 Anderson IA, Saukila LF, Robins JMW et al (2018) Factors associated with 30-day ventriculoperitoneal shunt failure in pediatric and adult patients. J Neurosurg 130(1):145–153. 10.3171/2017.8.jns17399 Muir RT, Wang S, Warf BC (2016) Global surgery for pediatric hydrocephalus in the developing world: a review of the history, challenges, and future directions. Neurosurg Focus 41(5):E11. 10.3171/2016.7.focus16273 Murshid WR, Jarallah JS, Dad MI (2000) Epidemiology of Infantile Hydrocephalus in Saudi Arabia: Birth Prevalence and Associated Factors. Pediatr Neurosurg 32(3):119–123. 10.1159/000028915 Ahmadvand S, Dayyani M, Etemadrezaie H et al (2020) Rate and Risk Factors of Early Ventriculoperitoneal Shunt Revision: A Five-Year Retrospective Analysis of a Referral Center. World Neurosurg 134:e505–e511. 10.1016/j.wneu.2019.10.108 BASCO LK, MOLECULAR EPIDEMIOLOGY OF MALARIA, IN CAMEROON. XIX. QUALITY OF ANTIMALARIAL DRUGS USED FOR SELF-MEDICATION (2004) Am J Trop Med Hyg 70(3):245–250. 10.4269/ajtmh.2004.70.245 Laxminarayan R, Duse A, Wattal C et al (2013) Antibiotic resistance—the need for global solutions. Lancet Infect Dis 13(12):1057–1098. 10.1016/s1473-3099(13)70318-9 Ayukekbong JA, Ntemgwa M, Atabe AN (2017) The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrob Resist Infect Control 6(1):47. 10.1186/s13756-017-0208-x Hart CA, Kariuki S (1998) Antimicrobial resistance in developing countries. BMJ 317(7159):647. 10.1136/bmj.317.7159.647 Ulep V, Cruz ND (2016) Analysis of out-of-pocket expenditures in the Philippines. Policy Notes 21:1–6 Office PS (2022) Health Spending Grew by 10.9 Percent in 2019. Accessed October 18, https://psa.gov.ph/pnha-press-release/node/163258 Office PS (2019) Annual Family Income is Estimated at PhP 313 Thousand. Published December 4, Accessed October 18, 2022. https://psa.gov.ph/pnha-press-release/node/163258 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Revision requested 21 Jun, 2024 Reviews received at journal 20 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers invited by journal 20 Jun, 2024 Editor assigned by journal 14 Jun, 2024 Submission checks completed at journal 14 Jun, 2024 First submitted to journal 13 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4578687\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":317425934,\"identity\":\"eb2c461e-83e6-434f-9761-f8b2c67dec98\",\"order_by\":0,\"name\":\"Kevin Ivan P. Chan\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACCQYGNgjreAOQMLAgRcuZAyAtEqRouZEA5RMCkrObnz34uYMhmu/m86sbfhRIMPC3dyfg1SItc8zcsPcMQ+7M2zllN3uADpM4c3YDXi1yEjlsErxtDLkbbuek3eABajGQyCWsRfIvSMvNM2k3/xCjRRqoRRpsyw32Y7eJskVyzjEzadk2idyZZ3LYbssYSPAQ9IvE7eZnkm/bbHL7jh9/dvPNHxs5/vZe/FqgEQEieQxALB78yhFaQID9AWHVo2AUjIJRMCIBAHmbRs7P0JoUAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of the Philippines Manila\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Kevin\",\"middleName\":\"Ivan P.\",\"lastName\":\"Chan\",\"suffix\":\"\"},{\"id\":317425935,\"identity\":\"2954e2b6-ae04-40a6-b65a-9a30200c22eb\",\"order_by\":1,\"name\":\"Abdelsimar Tan Omar II\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"McMaster University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abdelsimar\",\"middleName\":\"Tan Omar\",\"lastName\":\"II\",\"suffix\":\"\"},{\"id\":317425936,\"identity\":\"3384cc45-5b3a-49f0-b763-3e884fb5f6af\",\"order_by\":2,\"name\":\"Kathleen Joy O. Khu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of the Philippines Manila\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kathleen\",\"middleName\":\"Joy O.\",\"lastName\":\"Khu\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-06-14 01:12:44\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4578687/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4578687/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s00381-024-06651-x\",\"type\":\"published\",\"date\":\"2024-10-21T15:56:54+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":67681607,\"identity\":\"2aff85f1-f8ce-41fe-bdbd-b8f30a737eb2\",\"added_by\":\"auto\",\"created_at\":\"2024-10-28 16:03:22\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":571980,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4578687/v1/04f0f4de-95f2-408f-892f-8f55fd295935.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The economic burden of ventriculoperitoneal shunt insertion and its complications: Findings from a cohort in the Philippines\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eThe burden of congenital hydrocephalus remains high, especially in low- and middle-income countries (LMICs). [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e] Ventriculoperitoneal shunt (VPS) insertion, the standard of treatment for hydrocephalus, is one of the most commonly performed neurosurgical procedures, with approximately 5.5 per 100,000 patients undergoing VPS implantation annually. [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eHowever, VPS insertion is fraught with complications, and has a high likelihood of revisions and/or replacement requiring repeated admissions and operations.[\\u003cspan additionalcitationids=\\\"CR4\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e] Despite improvements in surgical technique and consistent use of perioperative antibiotics, shunt malfunction and infection occur in up to 41% and 7% of cases, respectively.[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e] Shunt failure and infection result in significant neurologic morbidity for the patient. Survivors of shunt infections have decreased intelligence quotients, increased frequency of seizures, increased psychomotor retardation, and decreased quality of life overall.[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e] Aside from the adverse effects on clinical outcomes, shunt failure also carries a significant financial burden on the family unit and on health systems. Its total expenditure per year has been estimated at 2\\u0026nbsp;billion dollars in the United States.[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eDespite this, only a few studies on the inpatient cost of shunt infection and malfunction have been published. [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e] Moreover, most of these studies were in high-income countries, even when the burden of hydrocephalus is much greater in LMICs. [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eWe thus conducted a retrospective cohort study in a public hospital in the Philippines to determine the cost of initial VPS insertion for congenital hydrocephalus, as well as the cost of subsequent admissions and operations for the management of shunt infection and shunt malfunction. We compared our findings with similar costing studies performed in other countries. We also determined which demographic and clinical characteristics were predictive of cost. These results can provide insight on the financial burden of VPS insertion in LMIC settings, and inform healthcare utilization decisions and cost-effectiveness studies.\\u003c/p\\u003e\"},{\"header\":\"MATERIALS AND METHODS\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy Design\\u003c/h2\\u003e \\u003cp\\u003e We performed a retrospective cohort study involving review of medical charts and financial records at the Philippine General Hospital, the largest public tertiary hospital in the country. We analyzed data of service patients, whose hospitalization is funded by government-provided health insurance, with no or minimal out-of-pocket expenditure.\\u003c/p\\u003e \\u003cp\\u003e We followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement guidelines for observational studies.[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatient Selection\\u003c/h2\\u003e \\u003cp\\u003eWe included all pediatric patients (aged 18 years and below) with a diagnosis of congenital hydrocephalus admitted during a 5-year period from January 2015 until December 2019, and who underwent one or more of the following surgical procedures: (1) initial VPS insertion; (2) shunt revision or insertion of a new VPS for shunt malfunction; and (3) shunt removal with or without temporary ventricular drainage for shunt infection. Shunt malfunction is defined as a non-infectious entity comprising of shunt blockage, shunt breakage, or dislodgement with the need for subsequent shunt surgery.[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] Meanwhile, shunt infection is diagnosed by the identification of a microorganism on gram stain or culture from cerebrospinal fluid (CSF) or wound swab, CSF pleocytosis obtained from a shunt tap associated with fever and/or shunt malfunction, clinical signs of wound infection, and/or peritonitis in a patient with a VPS. [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] Because COVID infection was a confounding variable which would intuitively increase cost, data from the year 2020 onwards were intentionally not included in the study.\\u003c/p\\u003e \\u003cp\\u003eWe excluded the following patients: congenital hydrocephalus associated with spina bifida or meningoceles; hydrocephalus secondary to tuberculous meningitis, brain tumors, hemorrhage, or trauma; and patients who left against medical advice or transferred to other institutions prior to completing treatment.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData collection\\u003c/h2\\u003e \\u003cp\\u003eThe inpatient hospitalization cost was determined from the hospital billing records. Medical implants used for CSF diversion such as VPS kits, Ommaya reservoirs, and external ventricular drainage (EVD) systems were not available in the hospital pharmacy and had to be sourced outside, so their costs were estimated based on the current retail price and added to the total cost. The following patient data were collected: age, sex, etiology of congenital hydrocephalus, length of hospital stay for each admission, presence of co-morbidities complicating the course of hospitalization, and outcomes of treatment.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eBaseline characteristics were summarized using means and standard deviations for the continuous measures and frequencies and percentages for categorical variables. Differences among groups were tested using one-way ANOVA for continuous variables (using the Bonferroni method to correct for multiple comparisons, when appropriate) and Chi-squared tests for categorical variables.\\u003c/p\\u003e \\u003cp\\u003eTo account for inflation across the 5-year study period, we converted the raw in-hospitalization cost for the years 2015\\u0026ndash;2018 to its 2019 equivalent with a consumer price index calculator for the Philippine peso (PHP) (\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.worlddata.info/asia/philippines/inflation-rates.php\\u003c/span\\u003e\\u003cspan address=\\\"https://www.worlddata.info/asia/philippines/inflation-rates.php\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTo analyze predictors of total cost of hospitalization, we conducted univariate linear regression model to assess the association of the following variables with cost: exposure category (uncomplicated, shunt malfunction, or shunt infection), age, sex, etiology, presence of comorbidities at baseline, presence or absence of other infections complicating the hospital course, number of surgeries, and length of stay. We also performed multivariable linear regression model, including the same predictors. The assumptions of linear regression \\u0026ndash; normality, linearity, and homoscedasticity \\u0026ndash; were checked by examining residual plots. The level of statistical significance was set at p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e \\u003cp\\u003eTo compare the in-hospitalization costs in our study with data reported in other countries, we performed a detailed literature review. We converted all mean cost values to their equivalent US dollar (USD) value on January 1 of the last year of the data collection period using a currency converter with historical data (\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.xe.com/currencytables\\u003c/span\\u003e\\u003cspan address=\\\"https://www.xe.com/currencytables\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e). We then converted the USD value to its January 2019 equivalent with the consumer price index calculator described above to account for inflation.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eA total of 230 CSF diversion procedures for congenital hydrocephalus were performed from 2015\\u0026ndash;2019. These were performed on 125 patients across 151 admissions, and included initial VPS insertions and subsequent re-do operations. The mean age of the cohort during the index VPS insertion was 9.8 months (range: 7 days to 8 years), with a slight female predilection (1.2:1). The most common etiology of the hydrocephalus was aqueductal stenosis (44%). Comorbidities were present in 32.8% of patients, and these included central diabetes insipidus, transient tachypnea of the newborn, and other congenital anomalies. Twenty-five patients (20%) had concomitant infection, most commonly hospital-acquired pneumonia.\\u003c/p\\u003e \\u003cp\\u003eOut of the 230 CSF diversion procedures performed, 107 were initial VPS insertions while 123 were re-do operations that addressed a shunt complication. Of the 125 patients included, 85 (68%) had an uncomplicated course, 15 (12%) were complicated by shunt malfunction, and 25 (20%) were complicated by shunt infection over a median follow up of 222 days.\\u003c/p\\u003e \\u003cp\\u003ePatients with a shunt-related morbidity consulted at the emergency department with signs of malfunction or infection at a mean of 3.2 years (range: 14 days to 8 years) from the initial VPS insertion. For the patients who developed shunt infection, 54% had a positive microbial growth on CSF culture. Patients who had shunt malfunction underwent an average of 2 operations (range: 1\\u0026ndash;4). The operation most commonly performed was a shunt revision. On the other hand, patients who had shunt infection underwent a median of 3 operations (range: 3\\u0026ndash;17). The types of procedures used to address the shunt infection were shunt removal and EVD insertion (64%), shunt removal only (24%), and shunt exteriorization (12%). Some patients had repeated bouts of ventriculitis and underwent EVD replacement while waiting for the infection to resolve. Once the infection was treated, majority (92%) underwent repeat VPS insertion. All the patients were discharged home after treatment. (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eBaseline characteristics and total cost of admission of patients who underwent shunt surgery with an uncomplicated course, complicated by shunt malfunction, and complicated by shunt infection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOverall\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUncomplicated Course\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eShunt Malfunction\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eShunt Infection\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNumber\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e125\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e85\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge at initial shunt, in months (SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e9.8 (16.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8.6 (11.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24.2 (35.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5.5 (5.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e67 (53.6%)\\u003c/p\\u003e \\u003cp\\u003e58 (46.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e47 (55.3%)\\u003c/p\\u003e \\u003cp\\u003e38 (44.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9 (60%)\\u003c/p\\u003e \\u003cp\\u003e6 (40%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e14 (56%)\\u003c/p\\u003e \\u003cp\\u003e11 (44%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.530\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEtiology of congenital HCP\\u003c/p\\u003e \\u003cp\\u003eAqueductal stenosis\\u003c/p\\u003e \\u003cp\\u003eDandy-Walker syndrome\\u003c/p\\u003e \\u003cp\\u003eHydranencephaly\\u003c/p\\u003e \\u003cp\\u003eOthers\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e55 (44%)\\u003c/p\\u003e \\u003cp\\u003e21 (16.8%)\\u003c/p\\u003e \\u003cp\\u003e8 (6.4%)\\u003c/p\\u003e \\u003cp\\u003e41 (32.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e41 (48.2%)\\u003c/p\\u003e \\u003cp\\u003e14 (16.5%)\\u003c/p\\u003e \\u003cp\\u003e7 (8.2%)\\u003c/p\\u003e \\u003cp\\u003e23 (27.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3 (20%)\\u003c/p\\u003e \\u003cp\\u003e4 (26.7%)\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003cp\\u003e8 (53.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11 (44%)\\u003c/p\\u003e \\u003cp\\u003e3 (12%)\\u003c/p\\u003e \\u003cp\\u003e1 (4%)\\u003c/p\\u003e \\u003cp\\u003e10 (40%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCo-morbidities present\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e41\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eConcomitant infection\\u003c/p\\u003e \\u003cp\\u003ePneumonia\\u003c/p\\u003e \\u003cp\\u003eSepsis\\u003c/p\\u003e \\u003cp\\u003eUrinary tract infection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003e0.400\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean number of operations (SD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.8 (2.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.0 (0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.7 (0.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4.8 (3.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eType and number of procedures\\u003c/p\\u003e \\u003cp\\u003eVPS insertion\\u003c/p\\u003e \\u003cp\\u003eShunt revision\\u003c/p\\u003e \\u003cp\\u003eShunt removal, \\u0026plusmn; EVD insertion\\u003c/p\\u003e \\u003cp\\u003eShunt removal, Ommaya\\u003c/p\\u003e \\u003cp\\u003eEVD insertion/ revision\\u003c/p\\u003e \\u003cp\\u003eETV\\u003c/p\\u003e \\u003cp\\u003eShunt Exteriorization\\u003c/p\\u003e \\u003cp\\u003eVentriculoatrial shunt insertion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e230\\u003c/p\\u003e \\u003cp\\u003e119\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e85\\u003c/p\\u003e \\u003cp\\u003e85\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e26\\u003c/p\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e119\\u003c/p\\u003e \\u003cp\\u003e29\\u003c/p\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003cp\\u003e47\\u003c/p\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean length of stay per admission (days)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e31\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e102\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean length of stay for total treatment (days)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e34.1 (54.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e12.2 (14.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e16.7 (13.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e118.9 (73.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean cost of total treatment\\u003c/p\\u003e \\u003cp\\u003e(PHP)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e94,573.50\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e40,587.20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e87,065.70\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e282,631.60\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean cost of total treatment (USD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1,815\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e779\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1,671\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e5,424\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003e*EVD - external ventricular drain; ETV \\u0026ndash; endoscopic third ventriculostomy; HCP \\u0026ndash; hydrocephalus; PHP \\u0026ndash; Philippine peso; SD \\u0026ndash; standard deviation; USD \\u0026ndash; United States dollar\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe mean length of stay for all patients was 34 days, with a significant difference among groups (uncomplicated, shunt malfunction, shunt infection; p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). The mean length of stay for uncomplicated patients (12.2 days) and those with shunt malfunction (16.7 days) were both significantly lower than the mean for patients with shunt infection (118.9 days, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e \\u003cp\\u003eThe mean cost of hospitalization for all patients was P94,573.50 (range: PHP 16,735.90\\u0026ndash;915,609.40), and was also significantly different among groups. In particular, pairwise analyses with the Bonferroni correction showed that the mean cost of patients who had shunt infection (PHP 282,631.60) was statistically higher than the mean cost for uncomplicated patients (PHP 40,587.20, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and the mean cost for patients who had malfunction (PHP 87,065.70, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e \\u003cp\\u003eUnivariate analysis showed the following significant predictors of total cost: occurrence of shunt infection, presence of comorbid congenital malformations at baseline, pneumonia and sepsis complicating the course of hospitalization, number of surgeries, and total length of stay. Multivariable analysis to determine the association of the predictors with the total hospitalization cost yielded a model that did not meet the assumptions of normality on analysis of residual plots. We thus proceeded to regress the \\u003cem\\u003elog\\u003c/em\\u003e of the raw cost on the predictors. This yielded a model which met the assumptions for linear regression. This model was able to explain 79% of the observed variability (adjusted R-squared: 0.7914). The following remained as significant predictors of cost in the latter model: shunt infection (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), shunt malfunction (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), pneumonia (p\\u0026thinsp;=\\u0026thinsp;0.006), sepsis (p\\u0026thinsp;=\\u0026thinsp;0.004), and length of hospital stay (p\\u0026thinsp;=\\u0026thinsp;0.005). (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eUnivariable and multivariable analysis of predictors of total cost of treatment\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUnivariate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMultivariate*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eExposure category\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUncomplicated\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRef.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRef.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMalfunction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.053\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eShunt Infection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.839\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.509\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.837\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.283\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEtiology\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAqueductal stenosis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRef.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRef.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDandy-Walker malformation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.424\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.382\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHydranencephaly\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.892\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.085\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePost-meningitic hydrocephalus\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.400\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.251\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eArachnoid cyst\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.661\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.829\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSchizencephaly\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.130\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.133\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMalformations of cortical development\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.720\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.271\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePresence of comorbidities at baseline\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.516\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInfection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePneumonia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.006\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSepsis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.004\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUTI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.560\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.442\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNumber of surgeries\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.066\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLength of stay\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.005\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003e*Multivariate regression\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThis study is the first to report the inpatient hospitalization cost of VPS insertion for congenital hydrocephalus and its complications in the Philippines, and is only the second study performed in a low- and middle-income country (LMIC). The mean cost of VPS insertion for congenital hydrocephalus in the Philippines was P94,573.50 (USD 1,815.23) for all patients and PHP 40,587.20 (USD 779) for those who did not develop any shunt complications. The cost was comparable to the one reported in Uganda, another LMIC, which showed a mean cost of USD 620 for an uncomplicated VPS insertion.[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] These values were only a fraction of the cost of the procedure in high-income countries. For example, studies from Australia, Canada, and the United States reported a mean cost of USD 11,836\\u0026ndash;62,850 for an uncomplicated shunt procedure after adjusting for inflation [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR11 CR12\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e] (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). These were 15 to 80 times more expensive than the mean cost in our cohort. The large disparity in cost may have been due to the setting of the study. Our institution is a public government hospital where physicians do not charge patients any fee for service. Moreover, the patients stayed in large hospital wards instead of individual rooms. Differences in the standard of care between developed and developing countries may also play a role.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eComparison of the cost of treatment for VPS insertion and its complications in other countries\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"12\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c10\\\" colnum=\\\"10\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c11\\\" colnum=\\\"11\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c12\\\" colnum=\\\"12\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAuthor, year\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePeriod covered\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCountry (WB classification)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c6\\\" namest=\\\"c4\\\"\\u003e \\u003cp\\u003eUncomplicated shunt\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c9\\\" namest=\\\"c7\\\"\\u003e \\u003cp\\u003eShunt Malfunction\\u003c/p\\u003e \\u003cp\\u003e(per admission)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c12\\\" namest=\\\"c10\\\"\\u003e \\u003cp\\u003eShunt Infection\\u003c/p\\u003e \\u003cp\\u003e(per admission)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMean cost (raw)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eMean cost in USD\\u003c/p\\u003e \\u003cp\\u003e(Jan 2019)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eLength of stay (days)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMean cost per admission\\u003c/p\\u003e \\u003cp\\u003e(raw)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eMean cost in USD\\u003c/p\\u003e \\u003cp\\u003e(Jan 2019)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eLength of stay (days)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eMean cost per admission (raw)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eMean cost in USD\\u003c/p\\u003e \\u003cp\\u003e(Jan 2019)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eLength of stay (days)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChan\\u003c/p\\u003e \\u003cp\\u003e2024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2015\\u0026ndash;2019\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003ePhilippines (LMI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePHP 40,587\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e779\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003ePHP 52,303\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1,004\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003ePHP 225,564\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e4,329\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e102\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePham\\u003c/p\\u003e \\u003cp\\u003e2013[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2007\\u0026ndash;2009\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAustralia (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAUD 13,905\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11,836\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e7.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eAUD 9,753\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e8,139\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e4.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eAUD 83,649\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e69,904\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e50\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eShannon 2011[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2000\\u0026ndash;2005\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUSA (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eUSD 3,964\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e5,232\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eUSD 23,541\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e31,541\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWarf\\u003c/p\\u003e \\u003cp\\u003e2011[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2005\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUganda (LMI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eUSD 470\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e620\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eUSD 875\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e1,155\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStone\\u003c/p\\u003e \\u003cp\\u003e2010[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2005\\u0026ndash;2006\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUSA (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eUSD 15,103\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e19,555\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003e90,257\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e116,864\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSimon 2008[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2003\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUSA (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eUSD 40,260\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e55,773\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e6.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eUSD 17,760\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e24,589\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e2.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eUSD 62,470\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003e86,540\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatwardhan 2005[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2000\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUSA (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eUSD 35,816\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e53,408\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBigio\\u003c/p\\u003e \\u003cp\\u003e1998 [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1990\\u0026ndash;1996\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCanada (HI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCAD 52,812\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e62,850\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eNR\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"12\\\"\\u003e*AUD \\u0026ndash; Australian dollar; CAD \\u0026ndash; Canadian dollar; LMI \\u0026ndash; low- and middle-income; HI \\u0026ndash; high-income; NR \\u0026ndash; not reported; USA - United States of America; USD \\u0026ndash; US dollar; WB \\u0026ndash; World Bank\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eUnsurprisingly, treatment costs increase if shunt complications occur. Although both shunt malfunction and infection will require re-operation, the management of these two disease entities differs greatly, translating into a large difference in treatment cost.[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e] Shunt malfunction without infection is usually managed with a single surgical intervention, such as revising the obstructed ventricular or peritoneal catheter or shunt valve. On the other hand, shunt infection requires at least two surgical interventions, namely, removal of the existing shunt system with or without EVD insertion, and insertion of a new shunt after completing a lengthy course of antibiotic treatment, making this type of shunt failure significantly more costly. [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eAn interesting finding was that in the 5-year study period, the number of re-do operations due to shunt complications outnumbered that of initial VPS insertions (123 re-do to 107 initial shunts). These numbers suggest that more resources are devoted to the treatment of shunt complications than to the initial shunt procedures. This is in contrast with a study done in the USA which showed that more initial shunt insertions were performed than re-do operations. [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e] In addition, the patients in our shunt infection subgroup underwent a mean number of 5 operations whereas patients in a US center with the same diagnosis underwent only 2.28 revisions. [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eIt has been established that the high cost of VPS treatment predominantly arose from the relatively high complication and revision rates.[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e] In our study, the mean cost of treatment of shunt malfunction without infection was PHP 87,066 or USD 1,671. This value is 2.1 times the cost of treatment of an uncomplicated VPS insertion (USD 779). For shunt infection, however, the mean cost of treatment was PHP 282,631.60 or USD 5,424.79, which is 7 times the cost of an initial shunt insertion.\\u003c/p\\u003e \\u003cp\\u003eIn comparison, patients with shunt malfunction in Uganda spent USD 1,155, which was nearly twice the cost of VPS insertion (USD 620). [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] In the USA and Australia, shunt malfunction cost USD 3,964\\u0026thinsp;\\u0026minus;\\u0026thinsp;24,589 per admission, with a mean length of hospital stay ranging from 2 to 4.9 days. [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eIn terms of shunt infection, the costs ranged from USD 31,541 to 116,864 in the USA and Australia [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e], which were several magnitudes larger than in our cohort (USD 5,639). However, the average length of stay was only 12\\u0026ndash;15 days in the USA [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e] and 50 days in Australia[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. These were in stark contrast to the mean hospital stay of 119 days in our cohort.\\u003c/p\\u003e \\u003cp\\u003eAside from shunt infection and malfunction, other predictors of cost included pneumonia, sepsis, and length of hospital stay. Studies in other settings showed similar findings and determined the following predictors for cost: shunt infection [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e], pre-operative comorbidities[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], number of surgeries [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e] and the length of stay [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eNotably, all the significant predictors we have identified in our study were modifiable risk factors and could serve as targets of improvement initiatives. In fact, given our data, by averting one case of shunt infection, the hospital can reallocate resources and surgically treat 7 other patients with congenital hydrocephalus.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePossible contributory factors\\u003c/h2\\u003e \\u003cp\\u003eRisk factors for shunt complications include patient-related and treatment-related factors. [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e] The patients in our cohort were from the lower income classes who could not afford expensive private medical care. It has been reported that patients\\u0026rsquo; ethnicity and socioeconomic status were significantly associated with VPS morbidity and mortality rates.[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e] A lower socioeconomic status was a significant predictor of higher cost of hospitalization for VPS insertion. [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e] Furthermore, hydrocephalus treatment in the developing world may be complicated by nutritional deficiencies, low infant birth weight, lower APGAR score, greater incidence of perinatal and neonatal infections, and delayed antenatal diagnosis. [\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e] Several of our patients had concomitant systemic infections that may have contributed to the risk of shunt infection.\\u003c/p\\u003e \\u003cp\\u003eIn our study setting, the majority of the VPS operations were performed by neurosurgery trainees. Studies have shown that the shunt complication rates were significantly higher in trainees than in attending neurosurgeons.[\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e] In addition, antibiotic treatment and antimicrobial resistance may present challenges in a developing country. The questionable quality of pharmaceutical products[\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e], suboptimal antibiotic dose[\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e], lack of appropriate drug regulatory mechanisms[\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e], lack of more potent antibiotics[\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e], and inappropriate prescription practices [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e] may lead to inadequate treatment of infection. [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBurden at many levels\\u003c/h2\\u003e \\u003cp\\u003eAlthough the cost of shunt insertion in the Philippines is lower compared to developed countries, it is important to emphasize that out-of-pocket payment is the largest source of healthcare funding in the country, comprising nearly half (47.9%) of the funding. [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e] Given that a Filipino family has an average monthly income of PHP 26,083 (USD 500) and average annual savings of PHP 75,000[\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e], a single hospital admission for an uncomplicated VPS insertion (USD 779) already poses a significant economic burden. The cost will increase even more for patients who develop shunt complications. Moreover, there are indirect costs of treatment such as lost income for the child\\u0026rsquo;s parents. Warf et al. elucidated the possible opportunity cost lost by the parents while their children were admitted for shunt failure. [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] The patients\\u0026rsquo; parents were mostly minimum salary workers, so the opportunity cost of their time, which could be spent earning, poses a burden on the family. [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eOur findings should serve as a wake-up call for the proper and timely management of congenital hydrocephalus and avoidance of treatment complications, directed towards healthcare providers, hospital administrators, and policy makers in the health sector. Although effective protocols for the prevention of shunt failure are beyond the scope of this paper, an optimistic recommendation would be to decrease the shunt malfunction and infection rates with the hope of lowering the cost of treatment. This study places a monetary value on shunt insertion, malfunction, and infection, and highlights the exorbitant costs associated with shunt failure. In this regard, budget reallocation to prevent shunt infection and malfunction may prove to be more cost-effective in the long run. Furthermore, clinical and cost-analysis research protocols should be aimed at decreasing the infection rate and cumulative shunt revision rates, which would ultimately result in improved patient outcomes and substantial cost savings. Lastly, the burden of hydrocephalus and its treatment and failure is intertwined with more general public health concerns such as malnutrition, communicable diseases, congenital risk factors, and parental education.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eThis paper has several limitations. First, this is a retrospective study with its inherent biases. Second, we only included patients with congenital hydrocephalus, and excluded patients with other forms of congenital lesions such as myelomeningocoele and those with acquired hydrocephalus. The cost of the treatment in these cases is expected to be higher compared to the costs presented in this paper. Third, the data was gathered from a public government hospital that serves indigent patients, so the costs of treatment are lower and would not be reflective of the costs in other hospitals in the country, especially the private ones. In addition, the members of the healthcare team did not charge patients for their services, contributing to a lower cost. Fourth, only the inpatient medical records were included in the review. Patients who underwent an initial VPS insertion and developed shunt failure may have consulted at other hospitals after the initial surgery, so the cost of their treatment would not be reflected in this study. Lastly, the reported costs were only limited to direct quantifiable cost during the patient\\u0026rsquo;s hospitalization, as reflected in the billing records. Indirect costs such as the potential loss of income of the parents and cost of outpatient visits, imaging studies, and medication were not included.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eThis study described the cost of VPS insertion and its complications. Predictors of cost included shunt infection, malfunction, pneumonia, sepsis, and length of stay. These can be potential targets of improvement initiatives to favorably affect health outcomes and reduce costs.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eAPGAR \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Apperance Pulse Grimace Activity Respiration score\\u003c/p\\u003e\\n\\u003cp\\u003eAUD \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Australian Dollars\\u003c/p\\u003e\\n\\u003cp\\u003eCAD \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Canadian dollar\\u003c/p\\u003e\\n\\u003cp\\u003eCSF \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Cerebrospinal fluid\\u003c/p\\u003e\\n\\u003cp\\u003eEVD \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;External ventricular drain\\u003c/p\\u003e\\n\\u003cp\\u003eLMIC \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Low- and middle-income country\\u003c/p\\u003e\\n\\u003cp\\u003ePHP \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Philippine peso\\u003c/p\\u003e\\n\\u003cp\\u003eUSA \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;United States of America\\u003c/p\\u003e\\n\\u003cp\\u003eUSD \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;US dollar\\u003c/p\\u003e\\n\\u003cp\\u003eVPS \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Ventriculoperitoneal shunt\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cu\\u003eAuthor contributions\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eKPC: conceptualization, methodology, data curation, formal analysis and investigation, writing \\u0026ndash; original draft preparation, writing \\u0026ndash; review and editing; ATO: conceptualization, methodology, formal analysis and investigation, writing \\u0026ndash; original draft preparation, writing \\u0026ndash; review and editing; KOK: conceptualization, methodology, formal analysis and investigation, \\u0026nbsp;writing \\u0026ndash; original draft preparation, writing \\u0026ndash; review and editing, supervision\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eFunding\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors did not receive any support from any organization for the submitted work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eCompeting interests\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to declare. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eEthics approval\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study has been approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-303-01).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eData availability\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData are available from the corresponding author upon reasonable request.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eLee TT, Uribe J, Ragheb J, Morrison G, Jagid JR (1999) Unique Clinical Presentation of Pediatric Shunt Malfunction. 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Policy Notes 21:1\\u0026ndash;6\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOffice PS (2022) Health Spending Grew by 10.9 Percent in 2019. Accessed October 18, \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://psa.gov.ph/pnha-press-release/node/163258\\u003c/span\\u003e\\u003cspan address=\\\"https://psa.gov.ph/pnha-press-release/node/163258\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOffice PS (2019) Annual Family Income is Estimated at PhP 313 Thousand. Published December 4, Accessed October 18, 2022. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://psa.gov.ph/pnha-press-release/node/163258\\u003c/span\\u003e\\u003cspan address=\\\"https://psa.gov.ph/pnha-press-release/node/163258\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"childs-nervous-system\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cnsy\",\"sideBox\":\"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)\",\"snPcode\":\"381\",\"submissionUrl\":\"https://submission.nature.com/new-submission/381/3\",\"title\":\"Child's Nervous System\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Economic burden, ventriculoperitoneal shunt, shunt malfunction, shunt infection, developing country\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4578687/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4578687/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eVentriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003e We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015\\u0026ndash;2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eA total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8 months (range: 7 days \\u0026ndash; 8 years). Over a median follow-up of 222 days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), shunt malfunction (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), pneumonia (p\\u0026thinsp;=\\u0026thinsp;0.006), sepsis (p\\u0026thinsp;=\\u0026thinsp;0.004), and length of hospital stay (p\\u0026thinsp;=\\u0026thinsp;0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5,425) than uncomplicated patients (PHP 40,587.20 or USD 779; p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1,671; p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThe study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The economic burden of ventriculoperitoneal shunt insertion and its complications: Findings from a cohort in the Philippines\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-07-01 08:46:15\",\"doi\":\"10.21203/rs.3.rs-4578687/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-06-21T16:30:18+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2024-06-20T19:26:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"114223374590445183598571922164880707451\",\"date\":\"2024-06-20T18:03:14+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-06-20T08:19:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-06-14T05:16:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-06-14T05:15:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Child's Nervous System\",\"date\":\"2024-06-14T01:11:25+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"childs-nervous-system\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cnsy\",\"sideBox\":\"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)\",\"snPcode\":\"381\",\"submissionUrl\":\"https://submission.nature.com/new-submission/381/3\",\"title\":\"Child's Nervous System\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"7ec12f09-f609-4603-9ca8-9aaac121035d\",\"owner\":[],\"postedDate\":\"July 1st, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-10-28T15:58:40+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4578687\",\"link\":\"https://doi.org/10.1007/s00381-024-06651-x\",\"journal\":{\"identity\":\"childs-nervous-system\",\"isVorOnly\":false,\"title\":\"Child's Nervous System\"},\"publishedOn\":\"2024-10-21 15:56:54\",\"publishedOnDateReadable\":\"October 21st, 2024\"},\"versionCreatedAt\":\"2024-07-01 08:46:15\",\"video\":\"\",\"vorDoi\":\"10.1007/s00381-024-06651-x\",\"vorDoiUrl\":\"https://doi.org/10.1007/s00381-024-06651-x\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4578687\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4578687\",\"identity\":\"rs-4578687\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}